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Oral Board Mastery > Infertility > Flashcards

Infertility Flashcards

1
Q

What are the specific goals of evaluation of infertile male:

A

Identify:

  1. potentially correctable conditions
  2. irreversible conditions that are amenable to ART using sperm of male partner
  3. irreversible conditions not amenable → donor sperm or adoption
  4. life- or health-threatening conditions underlying or associated medical comorbidities
  5. genetic abnormalities or lifestyle and age factors that may affect male patient or offspring (esp is ART employed)
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2
Q

When should infertility be evaluated?

A

After 6 months of attempted conception when a female partner is > 35 yo.

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3
Q

For infertility evaluation whom should be evaluated and what is included evaluation?

A

GUIDELINE STATEMENT 1

initial fertility eval, both male and female partners should undergo concurrent evaluation

GUIDELINE STATEMENT 2

evaluation should include reproductive history and one or more semen analysis (if 2, at least 1 mo apart)

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4
Q

Reference limits for SA by WHO:

A

Semen volume → 1.5 mL

Total Sperm # → 39 milllion/ejaculate

Sperm Concentration → 15 million/mL

Vitality → 58%

Progresive Motility → 40%

Total Motility → 40%

Morphology Normal Forms → 4%

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5
Q

Types of sperm abnormalities:

A

Azoospermia → no sperm

Teratozoospermia → abnormal form (macrospermia - large, globospermia - round - could be WBC)

Necrozoospermia → dead sperm

Asthenozoospermia → reduced or absent or aberrant motility

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6
Q

Whom should evaluate men with abnormal SA?

A

GUIDELINE STATEMENT 3

men with one or more abnormal semen parameters should be evaluated by male reproductive expert:

complete H&P

directed tests as indicated

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7
Q

Evaluation of male should be considered particularly when couples have:

A

GUIDELINE STATEMENT 4

Failed ART or recurrent reproductive losses (RPL)

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8
Q

Clinicians should counsel infertile men or with abnormal SA of which health risks associated with abnormal semen parameters:

A

GUIDELINE STATEMENT 5

infertility or abnormal SA may be harbinger of medical dz

Proven: testicular cancer, mortality, charleston comorbidity index

Possible: DMII, , MS, chronic epididymtiis

Unclear: prostate cancer, melanoma, other cancer, STI, thyroid disorders

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9
Q

Infertile men with specific conditions should be informed of which associated health conditions?

A

GUIDELINE STATEMENT 6

pts with identifiable causes of infertility should be informed of relevant, associated conditions

Klinefelters: testosterone deficiency (possible perinatal disorders, anomalies, genetic disorders, respiratory disorders, CVD, endocrine, malignant neoplasms)

Cystic Fibrosis: tooth enamel defects, pulmonary, pancreatic

Hypospadias: urinary anomalies

Cryptorchidism: testicular cancer

Testosterone deficiency: DMII, metabolic disorder, CVD, HTN, all cause mortality, CVD mortality, alzheimer’s (possible PAD, rapid bone lose, lung and testicular cancer, CCI, prostate cancer)

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10
Q

Couples with advanced paternal age (>40) should be counseled of increased risk:

A

GUIDELINE STATEMENT 7

of health outcomes for their offspring

(germ line mutations, chromosomal abnormalities, birth defects, chondrodysplasia, schizophrenia, autism)

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11
Q

What are risk factors associated with male infertility that should be discussed and counseled:

A

GUIDELINE STATEMENT 8

lifestyle, medication usage, environmental exposures

(i.e. obesity, diet, alcohol, smoking, steroids, stress, pesticides, metals [lead, zinc, copper], chemicals)

current data on majority of risk factors are limited

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12
Q

Results from SA should be used to:

A

GUIDELINE STATEMENT 9

guide mgmt. of patient, greatest clinical significance when multiple abnormalities present (OR of infertility inc with more abnormal parameters)

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13
Q

What labs are important in infertile men and for what indications?

A

GUIDELINE STATEMENT 10

FSH and testosterone

Low T < 300 → LH, estradiol, prolactin

impaired libido, ED, oligozoospermia, azoospermia, atrophic testis, evidence of hormonal abnormality on PE

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14
Q

Azoospermic men should be evaluated with what tests and why?

A

GUIDELINE STATEMENT 11

semen volume, PE, FSH

differentiate obstruction vs. impaired production

(low volume, acidic pH → obstruction)

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15
Q

Patient with primary infertility and azoospermia or severe oligospermia (< 5 million sperm/mL) (non-obstructive) should have:

A

GUIDELINE STATEMENT 12

Karyotype and Y-chromosome microdeletion analysis

likely have elevated FSH and testicular atrophy (possible impaired sperm production)

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16
Q

Patients with vasal agenesis or idiopathic obstructive azoospermia should have? what should partner have if concern?

A

GUIDELINE STATEMENT 13

CFTR mutation carrier testing (5T allele) q31.2 of Ch. 7

GUIDELINE STATEMENT 14

Men with CFTR, partner should have genetic evaluation

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17
Q

What is NOT recommended in initial evaluation of infertile couple?

A

GUIDELINE STATEMENT 15

DNA fragmentation analysis

GUIDELINE STATEMENT 18

Antisperm antibody (ASA) testing

*trauma, mumps, testis malignancy, vasal obstruction, vasectomy, patency of genital tract

GUIDELINE STATEMENT 21

Scrotal US

GUIDELINE STATMENT 22

TRUS

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18
Q

What could increased round cells on SA indicate? What concentration is concerning? What should patients be evaluated for? How do you treat infertility due to chronic prostatitis?

A

GUIDELINE STATEMENT 16

>1 million/mL differentiate from WBC (pyospermia)

*special stains differentiate germ cells from somatic cells

GUIDELINE STATEMENT 17

pyospermia should be evaluated for infection

*chronic prostatitis, abx 6 weeks, dx by alkaline pH and leukocytes on SA

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19
Q

What is the utility for testing antisperm antibodies? How are they tested? How treated?

A

GUIDELINE STATEMENT 18

ASA should not be done on initial evaluation

When it would change treatment → (poor motility-isolated asthenospermia, agglutination, or abnormal post-coital test, or unexplained):

trauma, mumps orchitis, testis malignancy, vasal obstruction, vasectomy that disrupts the blood-testis barrier, or the patency of the male genital tract allowing sperm antigens or genital tract infections to generate ASA → can result in sperm agglutination in the semen

  1. Mixed agglutination: mix sperm with RBC coated in human Ab, ASA will cause linking and agglutination of RBC
  2. Immunobead assay: polysaccharide beads with rabbit anti-human Ab, beads bind to sperm containing ASA

TX: oral steroids, ART

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20
Q

When couples have RPL, what tests are appropriate?

A

GUIDELINE STATEMENT 19

Karyotype and sperm DNA fragmentation

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21
Q

In differentiating between obstructive and non-obstructive azoospermia is there a role for dx testicular bx?

A

GUIDELINE STATEMENT 20

NO

*predicted from clinical and lab tests without surgical dx biopsy

*FSH >7.6 and testis longitudinal axis < 4.6 → 89% chance of spermatogenic dysfunction

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22
Q

When should clinicians recommend TRUS for infertility?

A

GUIDELINE STATEMENT 22

Not on initial evaluation

In men with SA suggestive of ejaculatory duct obstruction (EDO) (i.e. acidic-pH < 7, azoospermic, semen volume < 1.5 mL, normal serum T, palpable vas deferens)

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23
Q

For isolated small or moderate right varicocele, is any other imaging indicated routinely?

A

GUIDELINE STATEMENT

NO, abdominal imaging for this sole indication

(only consider if large and non-reducible)

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24
Q

What abdominal imaging is recommended if vasal agenesis is present?

A

GUIDELINE STATEMENT 24

Renal US to evaluate for renal abnormalities

(male genital tract derive from Wolffian or mesonephric tract, paired which forms epididymis, vs, SV → anomalies can lead to renal anomalies)

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25
Q

When should surgical varicocelectomy be considered for infertility? When should it not?

A

GUIDELINE STATEMENT 25

in men attempting to conceive who have palpable varicocele, infertility, and abnormal semen parameters, except azoospermic men

GUIDELINE STATEMENT 26

men with non-palpable varicoceles detected solely on imaging

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26
Q

In men with clinical varicocele and non-obstructive azoospermia, what is recommended?

A

GUIDELINE STATEMENT 27

absence of evidence supporting varicocele repair

proceed to ART

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27
Q

How is sperm retrieval recommended in men with NOA? Should any pharmacologic manipulation be utilized prior to surgical intervention?

A

GUIDELINE STATEMENT 28

microdissection testicular sperm extraction (micro-TESE)

*micro-TESE → wide opening of tunica albuginea to allow exam of multiple regions of tissue, each oriented in centrifugal pattern to parallel blood supply, allowing extensive search of all testis areas with limited devascularization

GUIDELINE STATEMENT 45

Patients with NOA there is limited data supporting pharmacologic manipulation such as SERMs, AIs, and gonadotropins prior to sx intervention

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28
Q

Sperm surgically retrieved fro ICSI may be:

A

GUIDELINE STATEMENT 29

fresh or cryopreserved

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29
Q

Where may sperm be extracted in men with obstructive azoospermia?

A

GUIDELINE STATEMENT 30

Testis or epididymis

30
Q

In men with aspermia, how may sperm collection be performed?

A

GUIDELINE STATEMENT 31

surgical sperm extraction, induced ejaculation (sympathomimetics, vibratory stimulation or electroejaculation)

31
Q

Infertility associated with retrograde ejaculation may be treated with:

A

GUIDELINE STATEMENT 33

sympathomimetics and arlkalinization of urine with or without urethral catheterization, induced ejaculation, or surgical sperm retrieval

32
Q

After vasectomy, what are options for couples desiring conception:

A

GUIDELINE STATEMENT 33

surgical reconstruction, surgical sperm retrieval, reconstruction with sperm retrieval for cryopreservation

33
Q

Patients with vasal or epididymal obstructive azoospermia, what procedure may be successful in returning sperm to ejaculate:

A

GUIDELINE STATEMENT 34

microsurgical reconstruction

34
Q

For infertile men with azoospermia and EDO, what are options to improve/assist in fertility?

A

GUIDELINE STATEMENT 35

transurethral resection of ejaculatory ducts or surgical sperm extraction (TESE, TESA, percutaneous epididymal sperm aspiration PESA)

(TRUS > 15 mm A/P diameter SV, dilated vasal ampula > 6 mm, prostatic cysts)

35
Q

How may male infertility be managed through advances:

A

GUIDELINE STATEMENT 36

ART through IVF/ICSI

36
Q

What should clinicians advise an infertile couple with low total motile sperm count on repeated SA?

A

GUIDELINE STATEMENT 37

IUI success may be reduced and treatment with ART (IVF/ICSI) may be considered

37
Q

Patients with hypogonadotropic hypogonadism SHOULD be advised of what in regards to fertility?

A

GUIDELINE STATEMENT 38

determining and treating the baseline etiology for disorder is recommended

38
Q

What can be used to treat infertile men with low testosterone?

A

GUIDELINE STATEMENT 39

Aromatase inhibitors (AIs), hCG, or selective estrogen receptor modulators (SERMs–Clomiphene)

or combination thereof

hCG is FDA approved, others are not

GUIDELINE STATEMENT 40

for men interested in current or future fertility, testosterone monotherapy should not be prescribed

39
Q

Patients with hyperprolactinemia SHOULD be advised of what in regards to fertility?

A

GUIDELINE STATEMENT 41

evaluate and treat etiology accordingly

(decreased libido and/or impotence and/or testosterone deficiency with low/low normal LH → prolactin level)

*medications can inhibit dopaminergic inhibition of prolactin → elevated prl

opioids, antipsychotics, antidepressants, antiemetics, prokinetics, antihypertensives

hypothyroidsim, stress, elevated estrogen, CKD, chest wall injuries

40
Q

Patients with idiopathic infertility should be counseled about treatment options:

A

GUIDELINE STATEMENT 42

use of SERMs has limited benefits relative to the results of ART

GUIDELINE STATEMENT 44

consider treatment using FSH analogue with aim to improve sperm concentration, pregnancy rate, live birth rate

(not FDA approved)

41
Q

In regards to fertility, what should clinicians counsel patients about supplements:

A

GUIDELINE STATEMENT 43

supplements (antioxidants and vitamins) are questionable, inadequate to support specific agents for this purpose

42
Q

What should clinicians discuss in regards to planned gonadotoxic therapies:

A

GUIDELINE STATEMENT 46

effects on decrease/altered sperm production prior to commencing therapy (chemo/RT)

GUIDELINE STATEMENT 47

pts undergoing chemo and/or RT should avoid pregnancy for at least 12 months after completing tx

GUIDELINE STATEMENT 48

encourage sperm banking, preferably multiple specimens, prior to commencement of tx

GUIDELINE STATEMENT 49

defer SA after gonadotoxic tx at least 12 (preferably 24) months after tx completed

43
Q

Name high risk and intermediate risk gonadotoxins:

A

high risk: cyclophosphamide, ifosfamide, busulfan, chlorambucil, procarbazine, mechlorethamine, MOPP, CHOP

intermediate risk: cisplatin, carboplatin, oxaplatin, doxorubicin, taxanes, paclitaxel, docetaxel, cabazitaxel, ABVD, BEP

44
Q

What risks regarding infertility should be discussed with patients undergoing RPLND?

A

GUIDELINE STATEMENT 50

aspermia

GUIDELINE STATEMENT 51

obtain post-orgasmic UA for men with aspermia

*ejaculation if reflex involving interplay of somatic, sympathetic, and parasympathetic pathways

Emission: sympathetic spinal cord reflex, fail to deposit sperm into prostatic urethra

Expulsion: antegrade flow through combined sympathetic and somatic pathways (urethral muscles and bladder neck closure), sympathetic nerve damage → failure of bladder neck to contract, semen can pass retrograde to bladder

Lumbar sympathetics T10-L2

45
Q

Men persistently azoospermic after gonadotoxic therapies, best treatment option?

A

GUIDELINE STATEMENT 52

TESE

46
Q

What are important questions to ask at an initial male infertility visit?

A
  1. (C) Childhood/birth issues illness/issue (viral orchitis or cryptorchidism)
  2. (M) ED, low libido, ejaculatory problems, prior fertility
  3. (F) Family hx of reproductive failure, birth defects, MR, or CF
  4. (I) Epididymitis or urethritis
  5. (T)Genital Trauma or prior pelvic or inguinal surgery
  6. (E) Gonadotoxin exposures such as RT, chemo, meds/supplements, recreational drugs (cannabis), use of lubricants
  7. (N) Prior neoplasia such as testicular cancer
47
Q

What elements of PE are important for infertility evaluation?

A
  1. Masses on DRE
  2. Penile Abnormalities
  3. Presence of varicocele
  4. Secondary sex characteristics (body habitus, hair distribution, gynecomastia)
  5. Testis size and consistency
  6. Presence of consistency of Vas Deferens
48
Q

What instructions should be given to patient prior to collecting SA for fertility?

A
  1. If case of febrile illness, should wait 2 months after illness resolved
  2. Period of abstinence 2-7 days prior
  3. Semen can be collected by masturbation or by intercourse using special collection condom that do not contain substances detrimental to sperm
  4. Semen can be collected at lab or home, should be kept room/body temp during transport and examined w/in 1 hour
49
Q

What elements of physical exam would suggest obstructive azoospermia?

A
  1. Absence of vas deferens
  2. History of inguinal/scrotal surgery (usually b/l)
  3. Hx of urethritis
  4. Low fructose levels in ejaculate
  5. Low volume ejaculate
  6. Midline mass felt on DRE
  7. Normal FSH
  8. Normal testis size
  9. TRUS findings: enlarged SV or ejaculatory ducts, midline prostatic cyst in urethra
50
Q

What genetic conditions result in azoospermia and how do you test for them?

A
  1. CF mutation, b/l absence of vas deferens → CFTR (5T allele)
  2. Klinefelters Syndrome → Karyotype (47, XXY)
  3. Structural Chromosomal disorders → Karyotype (translocation)
  4. Y chromosome microdeletions → Y chromosome microdeletions assay (A/B no sperm, C sometimes)
51
Q

Acceptable medications to treat hypogonadism in those desiring fertility? Unacceptable?

A

Acceptable

  1. Aromatase inhibitors (AIs: Anastrozole, Letrozole) → prevent conversion of testosterone to estradiol, thus decreasing negative feedback of estrogen at pituitary/hypothalamus level, thereby enhancing indirectly LH and FSH excretion from anterior pituitary
  2. hCG injection (2500-5000 IU 1-3 x week for 12-15 weeks) → biological activity of LH, directly stimulating testes to produce testosterone
  3. Selective estrogen receptor modulators (SERMs: Clomiphene citrate 25-50 mg/day x 3-6 mo, Tamoxifen) → blocks negative feedback of estrogen at pituitary/hypothalamus level, thereby enhancing indirectly LH and FSH excretion from anterior pituitary, increased LH/FSH should increase T production and spermatogenesis

Unacceptable

  1. Exogenous testosterone → increases negative feedback on hypothalamus and pituitary, resulting in low gonadotropins and low testicular testosterone which can inhibit spermatogenesis
52
Q

Appropriate sperm extraction for NOA?

A
  1. Micro-TESE
  2. TESA (testicular sperm aspiration)
  3. TESE
  4. Testicular mapping (multiple percutaneous bx according to template)
53
Q

Appropriate sperm extraction in patient who had prior vasectomy (obstructive azoospermia)?

A
  1. MESA (microsurgical epididymal aspiration)
  2. PESA (percutaneous epididymal sperm aspiration)
  3. TESA
  4. TESE
  5. Vasal sperm extraction (during vasovasostomy)
54
Q

How do you properly examine for varicocele?

A
  1. Scrotum should be warm (warm room, hands, heating pad)
  2. Determine testis size and consistence
  3. Examine prone and standing
  4. Examine during a Valsalva maneuver
55
Q

What are grades of varicoele?

A

Grade 1 → palpable only with patient performing Valsalva

Grade 2 → palpable w/o Valsalva

Grade 3 → visible through scrotal skin

56
Q

What are common theories of varicocele pathophysiology on fertility?

A

**hyperthermia → pampiniform plexus encircle testicular arteries, counter-current exchange to cool arterial blood reaching testis, varicoceles may affect this and elevate temperature, affect enzymatic function?

**hypoperfusion leading to hypoxia → increase in venous pressure elicits compensatory vasoconstriction in pre-capillary arterioles as mechanism to down-regulate arterial flow

**increased ROS → DNA fragmentation

**reflux of metabolic toxins from adrenal and/or kidney → toxic on testis?

**testicular hormonal imbalance → Leydig cell dysfunction and decreased intratesticular T

57
Q

What would you do if you found a right sided Grade 3 varcicocele?

A

RP imaging to r/o mass causing obstruction of right internal spermatic vein

58
Q

Indications for varicocele repair in infertile male? in general?

A
  1. semen abnormalities (oligoasthenozoospermia)
  2. palpable varicocele
  3. infertility (> 1 year attempting)
  4. female has normal fertility and young

Also:

  1. Adolescents with objective evidence of reduced ipsilateral testicular flow
  2. Adult men with palpable varicocele and abnormal SA not currently attempting but possibly in future to improve or stabilize semen parameters
  3. Pain, sx may not relieve pain (heaviness/dull ache, exacerbated by strenuous activity), if conservative measure prove inadequate
59
Q

What are the methods of varicocele repair?

A

Inguinal ligation (Ivanissevich procedure): incise over inguinal crease, incise external oblique aponeurosis, avoid ilioinguinal nerve, mobilize cord, dissect out cord and identify dilated spermatic veins, cut, clamp, ligate (usually 3), preserve testicular artery, close in layers

Laparoscopic varicocelectomy

Optimal magnification

Percutaneous venous occlusion (embolization)

RP high ligation (Palomo procedure): incise over internal inguinal ring, incise external oblique aponeurosis, spit internal oblique muscle, push peritoneum medial, clamp, cut, ligate (usually 3), preserve testicular artery, close in layers

Subinguinal ligation: make subinguinal incision, mobilize cord, ligate all veins, leave 2-3 lymphatics, preserve testicular artery, close in layers

60
Q

Describe complications of varicocele embolization:

A
  1. Epididymo-orchitis
  2. injury at puncture site (bleeding, false aneurysm, inadvertent cannulation of femoral artery)
  3. pampiniform plexus phlebothomosis and phlebitis
  4. radiation exposure
  5. skin infection
  6. spasm/dissection/perforation of venous tract
  7. contrast allergy reaction
61
Q

Describe complication of varicocelectomy:

A
  1. Hematoma
  2. Hydrocele formation
  3. Injury to vas deferens: if done perform VV with 9-0 or 10-0 nylon sutures
  4. skin/wound infection
  5. testicular artery injury (testicular atrophy): can use vasodilator such as paparverine or 0.25% mepivacaine
  6. failure (varicocele persistence/recurrence): can be caused by missing a vein or by compression of L renal vein on SMA “nut cracker syndrome”
62
Q

What is a “stress pattern” on SA?

A

consists of low count, poor motility, and poor morphology

consistent with varicocele but represent abnormal testicular function w or w/o varicocele

63
Q

How do you follow efficacy of varicocelectomy done for infertility

A

Q3 mo semen analysis for 1 year

64
Q

Risk factors for infertility:

A
  1. Loss of libido
  2. Reduction or loss of accessor glands
  3. Cryptorchidism
  4. Leydig cell hyperplasia
  5. Sertoli cell only
  6. DSD
  7. CF
  8. Retrograde ejaculation
  9. Anejaculation
65
Q

How is an infertile FEMALE evaluated:

A
  1. H&P
  2. Hormonal profile
  3. Basal body temp
  4. Hysterosalpingogram
  5. Post-coital test
  6. Laparoscopy
66
Q

What is sperm penetration assay (SPA)?

A

post coital testing in cases of hyperviscous semen, unexplained infertility, low or high volume specimens with good density

microscopic exam of cervical mucus shortly before ovulation w/in hours of intercourse to ID presence of sperm in mucus (normal >10-20 sperm/hpf with progressive motility)

67
Q

How do you treat vasal or epididymal obstruction

A

VV

vasoepididymostomy

epididymal sperm extraction

68
Q

How do you retrieve sperm from bladder?

A
  1. alkalinize urine 1 day before w/ NaHCO3
  2. Empty bladder to urethral cath
  3. rinse bladder with LR, leave 2 mL in bladder
  4. Masturbation
  5. Patient voids or sperm harvested with catheter
  6. concentrated w/centrifugation or ART
69
Q

How can fructose guide determination of type of azoospermia?

A

Negative Fructose → low ejaculate volume, seminal vesicle fluid not present

(EDO, primary/secondary testicular failure, b/l congenital absence vas, ejaculatory dysfunction)

Positive Fructose → retrograde ejaculation, b/l vasal obstruction, incomplete specimen collection since SV secretions presents

70
Q

Algorithm for Azoopermic male:

A
71
Q

CF in regards to infertility shows which symptoms?

A

Male infertility (99%)

absent/defective vas deferens, epididymis, or SV

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